The resident experience with psychological safety during interprofessional critical event debriefings

Abstract Objectives Interprofessional feedback and teamwork skills training are important in graduate medical education. Critical event debriefing is a unique interprofessional team training opportunity in the emergency department. While potentially educational, these varied, high‐stakes events can threaten psychological safety for learners. This is a qualitative study of emergency medicine resident physicians’ experience of interprofessional feedback during critical event debriefing to characterize factors that impact their psychological safety. Methods The authors conduced semistructured interviews with resident physicians who were the physician team leader during a critical event debriefing. Interviews were coded and themes were generated using a general inductive approach and concepts from social ecological theory. Results Eight residents were interviewed. The findings suggest that cultivating a safe learning environment for residents during debriefings involves the following: (1) allowing space for validating statements, (2) supporting strong interprofessional relationships, (3) providing structured opportunities for interprofessional learning, (4) encouraging attendings to model vulnerability, (5) standardizing the process of debriefing, (6) rejecting unprofessional behavior, and (7) creating the time and space for the process in the workplace. Conclusions Given the numerous intrapersonal, interpersonal, and institutional factors at play, educators should be sensitive to times when a resident cannot engage due to unaddressed threats to their psychological safety. Educators can address these threats in real time and over the course of a resident's training to enhance psychological safety and the potential educational impact of critical event debriefing.


INTRODUC TI ON Background
Interprofessional feedback and team skills training are important in graduate medical education and required by the Accreditation Council for Graduate Medical Education (ACGME). 1 Critical event debriefing is the practice of standardized team reflection aimed at incorporating improved behaviors and teamwork skills into clinical practice. These sessions are unique opportunities to provide direct interprofessional feedback to the resident physician in conjunction with the shared learning of debriefing. 2,3 Feedback and debriefing, both experienceinformed dialogues or "learning conversations," have common goals and attributes but different theoretical roots in medical education literature; critical event debriefing challenges the "contextual divide between feedback and debriefing, highlighting the overlap in purpose and structure." 4 Integrating feedback and debriefing into one standardized interprofessional session may not only be practical but could advance both conversational strategies as educational tools.
Much of the literature on interprofessional feedback after critical events has been conducted in simulated sessions, which differ from critical event debriefings in important ways. Simulated sessions have been coined "safe containers" for learning, with a predictable structure, and trained facilitators. 5,6 Unlike simulated patient care encounters, critical events in the clinical setting are high stakes, unpredictable, and without protected time and space to debrief. Furthermore, critical event debriefing participants-both the givers and the recipients of feedback-have varied relationships and levels of training. Because the clinical team composition is often different from one critical event to the next, interprofessional feedback in critical event debriefings may not have the advantage of an established teacher-learner relationship or educational alliance often present in simulations. 7 It is important to understand the residents' sense of psychological safety during clinical critical event debriefing and feedback sessions to determine if, and when, educators can capitalize on these learning conversations. Dr. Amy Edmonson defines team psychological safety as "a shared belief that the team is safe for interpersonal risk taking." 8 In critical event debriefings, team members may take risks by admitting errors or discussing opportunities for individual and team growth in clinical care, procedural skills, communication, or leadership skills. These real-world learning conversations in a team setting benefit from mutual respect, trust in the team, caring for each other as individuals, and confidence in oneself. When learners feel unrestrained from the judgment of the team and the feeling that they need to always project competence, they can fully engage with the learning opportunities, are more productive, and are more satisfied with their learning environment. 6,7,[9][10][11] Alternatively, psychological distress leads to poor workplace relationships, provider burnout, and cognitive barriers to learning. 6,10

Goals of this investigation
When residents engage in critical event debriefings, they may experience greater benefits from the learning conversation if they have greater psychological safety. Educators should be sensitive to times when a learner experiences threats to their psychological safety and address these threats. This study aims to explore residents' experiences with psychological safety during debriefings to identify the success factors and limitations in these dynamic and complex learning conversations.  12 These forms are collected and reviewed by the ED medical director and an assistant residency program director to address both systems and educational issues, respectively.

Selection of participants
All resident physician team leaders in a critical event debriefing in the previous 3 months at the start of the study period were invited to participate via email.

Measurements
One researcher, LH, conducted semistructured interviews asking residents to (1) describe their experiences participating in the debriefing sessions over the course of their residency, (2) discuss the nature of feedback received, and (3) reflect on factors that made them feel safe or less safe during these sessions (Appendix A).
Interviews were conducted via Zoom video conferencing and transcribed prior to analysis. Interviews lasted approximately 30 min each and no one else was present during the interviews. All interview transcripts were deidentified to maintain anonymity and reduce bias. This project was approved by the Community Medical Centers Institutional Review Board in Fresno, California.

Data analysis
We coded interview transcripts and generated themes with a general inductive approach using concepts from social ecological theory. Social ecological theory views individual behavior as a complex interplay between intrapersonal factors, interpersonal processes, institutional factors, community factors, and public policy. 12 The social ecological model for health promotion helps us understand that changes in the social environment produce changes in individuals, and those individual changes then alter the environment and culture of an institution. 12 For the purposes of this analysis, we focused on the first three compo-

Characteristics of study subjects
Fifteen emergency medicine residents led a critical event debriefing in the previous 3 months and were invited to participate in the study via email. Eight residents responded to the invitation to enroll and all eight completed an interview. This sample included one second-year, three third-year, and four fourth-year residents; five were female and three were male. Residents were not queried as to why they did or did not respond to the invitation to participate in the study.

Main results
Ten major themes were identified and grouped into (1) intrapersonal, (2) interpersonal, and (3) institutional factors that impacted resident psychological safety during a critical event debriefing. Table 1 provides an overview of the major themes with representative quotes.

Intrapersonal factors
Residents found meaning in validating statements from the inter-

Interpersonal factors
The importance of relationships with the interprofessional team was a dominant theme for all residents interviewed. Longitudinal relationships allowed for mutual trust, respect, and investment in each other's development. Residents also found debriefing with the team and being vulnerable deepened new or existing professional TA B L E 1 Summary of key themes with representative quotes.

Topic Area Theme Representative quotes
Intrapersonal Validation from the interprofessional team during debriefing contributes to professional identity development.
"I think it is good having other people share the journey, be present, maybe make you feel just a little bit more confident that despite something not going as you had hoped, there were things that were good, and you know these things." (int 1) "I came across as very nervous when I was early in second year, so I got a bunch of pep talks in my early debriefings, people reassuring me that I was doing a good job or that I was being loud enough for running the room adequately." (int 5) Prior experience with feedback increased comfort with team debriefing.
"I think when you play sports, you know your coaches are always giving you feedback all the time and so you just kind of get used to like feeling vulnerable. But you kind of realize it's not personal or you just realize, it's just part of it, you know." (int 8) "If I'm not getting feedback, then I'm not going to be improving. And then I'm going to be doing wrong by somebody in the future because I didn't receive feedback and I'm going to learn a habit that is bad … I don't want to just slide by and be okay, I want to be a good physician." (int 6) Residents may prioritize selfpreservation over debriefings.
"When you are transitioning to a higher acuity zone there is a potential for bad things to happen. I think it is a little bit harder to be as vulnerable … sometimes the feedback that you're getting from many different sources can be a little bit overwhelming, it's all important, but it can be just a little bit hard to chew." (int 1) Interpersonal Residents consider preexisting relationships and respect for interprofessional team members prior to initiating debriefing.
"I think with time as you build up more confidence and especially when you build up relationships with your team, they are able to be more honest with you and I think when you take their feedback, you take it very honestly also. You know that they're not doing it because they don't trust you or believe in you, they're doing it because they want to see you grow and I think that just takes time." (int 2) "Sometimes for example when you go into [the trauma zone] and you're new … it takes a little bit of time for you to develop those relationships with the trauma nurses. So, when you're in the debrief you almost kind of want to maintain a calm, cool, collected attitude a little bit." (int 6) "I feel just like attendings, the nurses watch us grow and they know what our weak points and strong points are at least the ones that have been up in [the high acuity zones] for a long time and so they have kind of watched our progression over years and they have a little bit better insight into what we're doing well and not doing well and so they can be really valuable people to get feedback from." (int 5) Attending partnership matters. "There have been like a couple situations where like the attending perhaps I was less comfortable with or who I felt was like not as open to that sort of thing where I kind of just wanted to focus on more you know the positives and negatives of the case rather than individual performance, particularly my own performance." (int 5) "An attending sets the tone for what type of feedback is being given. Like if the attending starts with a canned response like people are probably going to give canned responses and if the attending gives like a very specific useful response, people are going to probably continue that because they're setting the tone." (int 4) Unprofessional behavior limits safety.
"I think when it gets emotional and volatile and when people start either yelling, cussing, or being more abrasive … that makes me less inclined to want to engage with that person." (int 8) The resident's perception of their position on the team affects their attitudes toward debriefing.
"I think once you realize that can actually contribute to the way that you are as provider and a person then maybe it motivates you to do more. That the end of a code is not the end of that experience. There could be something you can do to motivate yourself and the team." (int 2) relationships, allowing for future meaningful feedback both in and outside critical event debriefings.
Several residents noted that attending physicians had the opportunity to set the tone of a debrief that either allowed for hon- Often the debriefings were held in the room with a deceased patient. Some residents felt this interfered with their sense of safety and openness.
Standardizing the process and providing departmentwide education on the importance of debriefing helped. One resident noted that the debriefing guide's introductory script that reinforces that it is a safe space for feedback and learning was specifically helpful.
An institutional culture supportive of learning with multiple interprofessional learners allowed for vulnerability and openness to feedback. Residents were more willing to acknowledge their role as a learner if they were accompanied by other learners. When other members of the interprofessional team were also in explicit learning

Topic Area Theme Representative quotes
"I think that for me feedback is a way to give a lot of meaning and purpose to really tough situations. Like okay, this is really hard, this patient is really sick, like what can we learn from this to make this situation, as hard and tough and it was, or if someone passed, you know, how sad it was for the family … how do I make this experience more meaningful so that person and that person's illness has a bigger purpose than even just that experience?" (int 6) Institutional A standardized process lowers barriers to initiating team debriefing.
"I'm certainly not a person to push people if I get an immediate like reluctance to it. I think initially there was that and it's become that debriefing has become a little bit more ingrained in the culture where it becomes easier, and because it becomes easier, I feel safer even to bring it up in the first place if that makes sense?" (int 4) "It's understood that it's to improve patient care and it improves the way that the team can provide care for them, for the patient, and so I think the feedback that's delivered, it's for good intentions. If anything, the feedback that's received is ultimately to become a better clinician from the resident standpoint and from our team's standpoint it's just to be better providers. So, I think it's a good setting for us to be honest with each other and to kind of point out some issues that we can hope to improve on in the future." (int 2) Lack of private space and uninterrupted time limits engagement.
"I mean our department is kind of hectic all the time and it's hard to get people to all gather in one space at all but then to find a space where you can kind of talk and have things be quiet and subtle for a little while is difficult." (int 5) "I've always done the debrief in the room with the patient which I think actually could interfere especially if the patient has passed and such." (int 6) Having a department with multiple interprofessional learners increases resident's participation.
"I think another thing that kind of made me feel very safe is the fact that the nurses that were there that day were also learners … and so those people also had their own feedback for themselves and so I felt like everyone was kind of on the same page of like okay we're all trying to figure this out together, and we all kind of know how things are supposed to happen, but someone is better at this than us." (int 3) "I think when you're willing to be vulnerable you like drop yourself way down [in the hierarchy] and you allow yourself to be a position where if people want to, they could really take advantage of that. But I think in my experience when people see you do that, they also are willing to kind of step down into your level and open up the space where you all are at that and improving and growing." (int 6) TA B L E 1 (Continued) roles, it changed the resident's sense of hierarchy and allowed the resident to feel more comfortable also identifying as a learner.

DISCUSS ION
In resident education, critical event debriefings can provide unique opportunities to understand and learn from complex clinical situations, process emotionally charged events, identify areas for quality improvement, and strengthen relationships among the interprofessional team; however, these conversations can also threaten a resident team leader's reputation and credibility. 14 In the high-stakes field of medicine, revealing imperfection and weaknesses can be daunting, especially among learners. 15 The pressure for a resident to appear competent and hide vulnerabilities impedes learning and can cause significant mental stress. 15

LI M ITATI O N S
This study has several factors that limit the generalizability of our findings. This is a single-center study with a limited sample size that This study also did not explore the role of age, gender, ethnicity, sexual orientation, or other personal identifying characteristics on psychological safety. The tension of credibility and vulnerability can vary depending on personal identifying characteristics. Further research that addresses these in the feedback experience is critical to understanding and improving the learning environment.

CON CLUS IONS
In summary, this study suggests that cultivating a safe learning environment for residents in critical event debriefing involves the following key elements: (1) allowing space for validating statements; (2) supporting strong interprofessional relationships; (3) providing structured opportunities for interprofessional learning; (4) encouraging attendings to model vulnerability and set the tone for honest, specific feedback; (5) standardizing the process of debriefing; (6) rejecting unprofessional behavior; and (7) creating the time and space for the process in the workplace.
Educators can address these intrapersonal, interpersonal, and institutional factors when establishing and maintaining a critical event debriefing program to capitalize on learning conversations for resident physicians.

AUTH O R CO NTR I B UTI O N S
Lily Hitchner, Stacy Sawtelle Vohra-study concept and design. Lily

This project was supported by a 2020 Innovations Funding for
Education grant from the UCSF Academy of Medical Educators and UCSF Fresno.

CO N FLI C T O F I NTER E S T S TATEM ENT
The authors declare no conflicts of interest.